Billing for noncredentialed providers

Q: I used to work in the billing department for a group practice. We used to bill services performed by noncredentialed physicians with credentialed physicians' numbers. I openly questioned the legality of this practice and was assured that it was legal. Upon further research, I realized that my initial suspicions might have been valid. Is this practice legal, or does it constitute insurance fraud?

A: I will leave the legal issues of this question to the attorneys and answer this question from a coding perspective. This question will come into play mainly in two scenarios:

when a provider (new or established) is not credentialed with a particular insurance carrier, and

when a nonphysician provider (NPP) is not recognized by an insurance carrier for credentialing purposes.

Other related scenarios that I will discuss include billing when a locum tenens or reciprocal billing arrangement is in place.

NONCREDENTIALED PROVIDERS

The most common situation, and I believe the one to which you are referring in your question, is when a new or established provider hasn't been credentialed by an insurance company. This happens when a provider is hired right out of residency or from another practice (in- or out-of-state). The question is also raised when a practice has merged (requiring a new tax ID for that practice) or has added a new practice location.

Credentialing providers has become a specialty unto its own, requiring knowledge of the application processes for the national provider identifier (NPI), Medicare, Medicaid, and commercial insurance companies. Each step must be taken for providers to be credentialed in your practice. Almost all of these application processes may be undertaken online (except for some of the smaller payers), but they still are time-consuming and require advance planning.

Offices sometimes believe they can bill noncredentialed provider services under a credentialed provider's NPI until the new provider is credentialed. This action would inappropriate and would lead to audit recoupment and possible investigation.

All services must be billed under the care-rendering provider's NPI. The only exception would be when one provider is replacing another provider and a locum tenens or reciprocal billing arrangement has been established between the original and replacement providers. I will address these scenarios in more detail later.

When a practice has merged and acquires a new tax ID, each provider practicing at that location must be credentialed under the entity's new name, if applicable, and new tax ID. Additionally, credentialing is required for each provider rendering services at a new practice location.

For each of these situations, a provider must be credentialed to be able to bill for services he or she has rendered.

PROVIDERS NOT RECOGNIZED FOR CREDENTIALING

Some commercial insurance carriers do not recognize certain NPPs to be credentialed. In these situations, incident-to billing (billing under a doctor's NPI) can be used only when all incident-to guidelines have been met.

The Centers for Medicare and Medicaid Services developed incident-to guidelines, and many commercial insurance carriers recognize them as well. Because many carrier guidelines have changed, check with each individual payer before billing incident-to for your NPPs, even if you have billed this way in the past. Incident-to requirements are very specific:

The services are an integral, although incidental, part of the physician's professional service.

The services commonly are rendered without charge or included in the doctor's bill.

The services are of a type commonly furnished in physicians' offices or clinics.

The services are furnished under the doctor's direct personal supervision and are furnished by the physician or by an individual who is an employee or independent contractor of the doctor. Direct supervision does not require the physician's presence in the same room, but the doctor must be present in the same office suite and immediately available.

The physician must perform the initial service and subsequent services of a frequency that reflects his or her active participation in the management of the course of treatment.

The doctor or other provider under whose name and number the bill is submitted must be the individual present in the office suite when the service is provided.